Vesicovaginal and Ureterovaginal Fistula 

Updated: Dec 18, 2018
Author: Sandip P Vasavada, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS 

Overview

Practice Essentials

A fistula is defined as a communication between 2 organ sites. Vesicovaginal fistula is a free communication between the urinary bladder and the vagina. The urine from the bladder freely flows into the vaginal vault, leading to total or continuous incontinence. Ureterovaginal fistula is a communication between the distal ureter and the vagina. The urine from the ureter bypasses the bladder and flows into the vagina. This also results in total or continuous incontinence. Urinary incontinence resulting from these fistulas may mimic symptoms of stress urinary incontinence. 

Obstetric trauma resulting in fistula formation is most common cause of urinary fistulas in developing countries. In developed countries, more than 50% of such fistulas occur after hysterectomy for benign diseases such as uterine fibroids, menstrual dysfunction, and uterine prolapse.[1, 2]  

The acute onset of urinary incontinence occurring shortly after a difficult hysterectomy should raise suspicions for vesicovaginal or ureterovaginal fistulas. If vesicovaginal or ureterovaginal fistula is suspected, as an immediate therapy, insertion of a urethral catheter to minimize urine leakage and the patient's distress can be considered. Spontaneous closure can occur in up to 15% of cases using catheter drainage Conservative approaches are more likely to be successful for nonradiotherapy fistulae.[3]

The commonly chosen surgical approaches for the correction of vesicovaginal fistula include the transabdominal and transvaginal approaches. Historically, the site of the fistula often dictated the surgical approach. Supratrigonal fistulas (fistulas above the interureteric ridge) were typically approached transabdominally. Infratrigonal fistulas (fistulas below the interureteric ridge) were corrected transvaginally. Most surgeons prefer the transabdominal approach for both supratrigonal and infratrigonal fistulas because access to the fistula is easier. Supratrigonal fistulas are more difficult to reach transvaginally.

Currently, the transvaginal approach is preferred because it results in less morbidity. The transvaginal approach is the safest and most comfortable for the patient. Additionally, it has been reported that closure is significantly more likely to be achieved using a transvaginal approach than a transabdominal technique (90.8% success vs 83.9%).[3] However, if the fistula site is difficult to access transvaginally, the transabdominal route remains a safe and effective alternative.

For excellent patient education resources, see eMedicineHealth's patient education articles Intravenous Pyelogram, Cystoscopy, and Foley Catheter.

Pathophysiology

Unrecognized bladder injury during a difficult hysterectomy or cesarean delivery may result in vesicovaginal fistula formation. Most vesicovaginal fistulas are caused by dissection of the bladder during the mobilization of the bladder flap, which causes devascularization or an unrecognized tear of the posterior bladder wall. Alternatively, if the vaginal cuff suture was unknowingly incorporated into the bladder, this can result in tissue ischemia, necrosis, and subsequent fistula formation.

The ureter may become injured during the dissection around the infundibulopelvic ligament or ligation of the uterine vessels. Unexpected pelvic hemorrhage may obscure the surgeon's vision and result in ureteral injury that manifests as delayed ureterovaginal fistula.

Fistulas resulting from vaginal birthing occur during difficult or prolonged labor. The head of the fetus compresses the trigone or the bladder neck against the anterior arch of the pubic symphysis. This may result in tissue ischemia, necrosis, and eventual fistula formation. Today, this is rare in the United States.

Etiology

In the United States, more than 50% of vesicovaginal and ureterovaginal fistulas occur after hysterectomy for benign diseases such as uterine fibroids, menstrual dysfunction, or uterine prolapse.

Pelvic radiation is the primary cause of delayed fistula, which can occur from one month to many years after the initial radiation treatment. Radiation treatment is typically used to treat cervical or endometrial carcinoma. Vesicovaginal fistula may occur with or without cancer recurrence.

In developing countries, obstetrical complications are the most common cause of vesicovaginal and ureterovaginal fistulas. This may develop in cases of long-standing and obstructed labor leading to pressure necrosis on the anterior vaginal wall. Fistulas in this setting may be large and have extensive local tissue damage and necrosis.

Epidemiology

A systematic review over a 35-year period reported 83.2% of fistula in developed countries were iatrogenic whereas 95.2% of fistula in developing countries were the result of obstetric complications.[3]  However, the incidence of vesicovaginal fistula resulting from hysterectomy is estimated to be less than 1%. Approximately 10% of such fistulas may involve one or both ureters. Some fistulas may be more complex, involving adjacent organs. If the rectum is involved in the inflammatory reaction, rectovaginal fistula may develop.[4]

The estimates of the global prevalence of untreated obstetric fistula vary from 654,000 to 3,500,000. In Ethiopia, Malawi, and Bangladesh, reported incidence ranges between 1.5 and 1.7 per 1000 women. An estimated 33,451 new cases occur annually in rural sub-Saharan Africa. Hospital-based reports show the incidence to be between 0.6 and 6.5 per 1,000 births.[5]

Prognosis

The success rate of vesicovaginal and ureterovaginal fistula repair approaches 90% at first attempt and approaches 100% after a second attempt. However, realize that the second operation is more extensive and more complex than the first operation. Often, the surgical approach must be changed, and additional procedures, such as Martius flap, peritoneal flap, omental flap, or gracilis muscle flap, must be performed in combination with the fistula repair. For complex repairs involving radiated tissues, the success rate is less than 90%, but, for experienced surgeons, the outcome remains highly successful.

Keep in mind that the first operation is the best one. Any attempts at further surgical repair after an initial failed approach may yield unsatisfactory results. To maximize outcomes and minimize further potential morbidity, it is highly recommended to seek out a surgeon who is adept at this type of reconstruction and performs this in a high volume.

 

Presentation

History

Suspect a possible fistula when a patient reports acute onset of urinary incontinence after a recent gynecologic surgery (eg, hysterectomy or cesarean delivery), if the degree of incontinence is disproportional to the physical findings, or if the medical history and the nature of incontinence are inconsistent.

The clinical history of vesicovaginal or ureterovaginal fistula is usually straightforward. Typically, a gynecologic procedure, such as hysterectomy, is involved. Often, the operation is reported to have been technically challenging. Poor intraoperative exposure, coupled with heavy bleeding at the operative site, are often risk factors. Associated bladder injury may have occurred and may have been repaired.

Patients with vesicovaginal fistula often report painless unremitting urinary incontinence. This is also called total, or continuous, incontinence requiring the use of several thick pads per day. The urinary incontinence mimics stress incontinence, in which urine loss is more dramatic during physical activities or when the individual stands upright from a lying position. Symptoms of urinary frequency and urgency are typically absent. Patients may notice a clear vaginal discharge

Acute onset of vesicovaginal fistula immediately after pelvic surgery does not cause constitutional symptoms. If the Foley catheter is still in place, the first sign of impending fistula formation is the presence of hematuria.

Conversely, patients with ureterovaginal fistula may experience constitutional symptoms of fever, chills, malaise, flank pain, and gastrointestinal symptoms in association with continuous urinary incontinence. Constitutional symptoms may result from hydronephrosis secondary to ureteral obstruction or urinary extravasation into the retroperitoneal space. Acute-onset ureterovaginal fistulas are often associated with a difficult postoperative course. These patients present with fever, ileus, and abdominal and flank pain.

Approximately 10-15% of fistulas do not appear for 10-30 days. Some fistulas may not manifest for months. Radiation-induced fistulas may not become apparent for many years after radiation treatment. The development of a typical radiation-induced fistula is heralded by radiation cystitis, hematuria, and bladder contracture. These symptoms are improved dramatically by the sudden presence of vesicovaginal fistula.

Physical Examination

During a physical examination, patients with newly onset ureterovaginal fistulas may demonstrate flank or abdominal tenderness due to hydronephrosis and/or urinary extravasation into the retroperitoneal space. Patients with vesicovaginal fistulas do not present with abdominal or flank symptoms.

A detailed pelvic examination reveals clear fluid pooling at the apex of the vagina. On close inspection, a pinpoint opening at the vaginal apex is often visualized in mature fistulas. When a fistula has not yet matured (immature fistula), inflamed erythematous vaginal mucosa is visible, with granulation tissue surrounding the fistulous tract. The fistulous opening is often difficult to localize in immature fistulas. In addition, pelvic examination may be tolerated poorly by the patient, further complicating the examination. In these situations, pelvic examination under general anesthesia is warranted.

Vaginal view of vesicovaginal fistula. Vaginal view of vesicovaginal fistula.
 

Workup

Laboratory Studies

If the presence of a vesicovaginal or ureterovaginal fistula is in doubt, vaginal secretions and fluid pooling in the vaginal vault should be sent for creatinine level evaluation. Serum creatinine should be drawn simultaneously, and that level should be compared with the fluid creatinine. If the fluid creatinine level is significantly higher than the serum creatinine, this confirms that the fluid is urine. If fluid creatinine test result is equivocal but a fistula is still suspected, proceed with a complete fistula workup, as discussed below.

Urinalysis and urine culture are used to rule out coexisting urinary tract infection.

Electrolyte panel (Chem 7) is used to evaluate renal function.

Complete blood cell (CBC) count is used to rule out systemic infection.

Imaging Studies

Radiographic imaging should include intravenous pyelography (IVP) or CT urography to rule out coexisting ureterovaginal fistula or ureteral obstruction. When a ureter is involved in the margin of the vesicovaginal fistula, IVP may demonstrate a standing column of contrast within the ureter, extravasation of contrast around the distal ureter, or hydronephrosis.

Cystography often demonstrates contrast leaking from the fistula tract. This confirms the presence of vesicovaginal fistula. (see image below)

Cystogram of vesicovaginal fistula. Note the contr Cystogram of vesicovaginal fistula. Note the contrast extravasating from the bladder into the vaginal canal.

Other Tests

Double dye test

Frequently, the double dye test is useful for diagnosing vesicovaginal fistula. In this test, the patient ingests oral phenazopyridine (Pyridium), and indigo carmine or methylene blue is instilled into the bladder via a urethral catheter. Pyridium turns urine orange, and methylene blue (or indigo carmine) turns urine blue. A tampon is placed into the vagina. If the tampon turns blue, suspect vesicovaginal fistula. If the tampon turns orange, suspect ureterovaginal fistula. If the tampon turns blue and orange, suspect a combination of vesicovaginal and ureterovaginal fistulas.

Diagnostic Procedures

Cystoscopy

Cystoscopy with concurrent vaginal speculum examination helps determine the location and size of the fistula in relation to the vaginal cuff, trigone, and ureteral orifices. In addition, it reveals the degree of inflammatory reaction and the number of fistulas present. Most fistulas discovered after hysterectomy are located immediately behind the interureteric ridge and on the anterior vaginal vault.

Cystoscopic view of vesicovaginal fistula. Cystoscopic view of vesicovaginal fistula.

Retrograde pyelography

This is the most definitive test to determine the presence of ureterovaginal fistula. Retrograde pyelography must be performed if IVP findings are abnormal or if the fistula site is difficult to locate. Performing bilateral retrograde ureteropyelography is often important because both ureters may be injured.

Histologic Findings

If the fistulous tract is excised as part of the repair technique, the specimen should be sent for pathologic evaluation to review the histologic findings. Pathologic findings vary depending on the cause of the fistula and may include foreign body,[6] giant cell reaction, malignancy, or chronic inflammation.

Giant cell reaction may be present if a foreign body was part of the cause of the fistula (eg, a nonabsorbable suture ligature of a uterine vessel catching the vaginal cuff and the bladder wall).

Radiation-induced fistulas are due to late changes caused by the radiation. After cessation of radiation therapy, fibrosis occurs in the bladder lamina propria. As fibrosis occurs in the subepithelial tissues, hyalinization of the connective tissues occurs. Often, large bizarre fibroblasts, ie, radiation fibroblasts, are encountered. An obliterative arteritis may be observed in medium-to-small vessels. These vascular changes may result in atrophy or necrosis of the bladder epithelium, causing ulceration or the formation of fissures. Again, it is important to rule out local cancer recurrence, especially in the setting of prior radiation therapy.

Fistulas due to cervical carcinoma may demonstrate either squamous cell carcinoma or adenocarcinoma. Fistulas due to iatrogenic injury manifest as signs of acute and chronic inflammation. The presence of abundant neutrophils suggests an acute inflammatory response. In patients with chronic inflammation, the predominantly lymphocytic infiltrate is associated with macrophages. In addition, interstitial tissue fibrosis and necrosis may be present.

 

Treatment

Approach Considerations

No medical therapy is available for the management of vesicovaginal and ureterovaginal fistula. However, conjugated estrogen (oral or transvaginal) helps vaginal tissues become softer and more pliable for upcoming fistula repair. This is especially important for postmenopausal women and women with atrophic vaginitis.[7]

For personal hygiene and skin care, sitz baths with a solution of permanganate or baking soda douches may be helpful.

For a small fistula, an initial trial of urethral catheter drainage may be attempted for 4-6 weeks. However, catheter drainage and/or fulguration of the edges of the fistula tract less often results in a cure. Small fistulas have a higher likelihood of healing with catheterization. Furthermore, in the rare series of patients who were successfully managed with fulguration, optimal success was achieved in patients who had longer and narrower fistulas, as opposed to short and wide ones.

Vesicovaginal and ureterovaginal fistulas recognized within 3-7 days after the causative operation may be repaired immediately via a transabdominal or transvaginal approach. Fistulas identified after 7-10 days postoperatively should be monitored periodically until all signs of inflammation and induration have resolved. Before embarking on fistula repair, the fistula tract should be well epithelialized and the vaginal wall should be soft and supple.

The traditional approach has been to wait at least 3-4 months before attempting fistula closure. However, this philosophy has been challenged. Some surgeons have successfully closed the fistula with or without using a tissue interposition, such as Martius flap or peritoneal flap, without waiting 3-4 months. The main issue being that satisfactory tissue quality and healing must be evident or the operative intervention may not be satisfactory.

Patients with a history of multiple failed repairs, patients with associated enteric fistula with pelvic phlegmon, or patients with a history of pelvic radiation should not undergo fistula repair for at least 6-8 months.

The presence of an active vaginal infection or persistent inflammatory or malignant process at the fistula site is a contraindication to surgical repair. Historically, the transvaginal approach has been contraindicated for supratrigonal fistulas. However, this is no longer an absolute contraindication. Whether to use a transabdominal or transvaginal approach is now dictated by the surgeon's experience and preference and ease of access to the fistula site.

In the past, surgical repair of any vesicovaginal fistula before 3 months was discouraged for fear of recurrence and inadequate healing. However, the principle of delayed repair is no longer absolute. The timing of fistula repair is now dictated by the nature of the local tissues around the fistula site. Surgical repair may commence if no vaginal infection is present and if the inflammatory process at the fistula site has resolved.

Surgical Therapy

The main factor in correcting vesicovaginal fistula is to separate the fistulous communication between the bladder and the vagina. This can be accomplished by inserting interposing tissue between the 2 organs and obtaining a watertight tension-free closure.

Pinpoint fistulas may respond to conservative management with urethral catheter drainage and fulguration of the fistulous tract, but success rates may be low. Persistent incontinence after an adequate period of watchful waiting requires open exploration and formal fistula repair.

Historically, the site of the fistula often dictated the surgical approach. Supratrigonal fistulas (fistulas above the interureteric ridge) were typically approached transabdominally. Infratrigonal fistulas (fistulas below the interureteric ridge) were corrected transvaginally.

The transvaginal approach is the safest and most comfortable for the patient. A history of previous failed repairs does not preclude transvaginal reconstruction. Fistulas located in the infratrigonal area, fistulas near the bladder neck, and those occurring after hysterectomy are usually amenable to transvaginal reconstruction. Transvaginal repairs do not require excision of the fistula tract.[8]

In corrections of extensive fistulas after radiation therapy, a combined transvaginal and transabdominal approach with fixation of the omentum in the space between the vagina and urinary bladder is often useful. Increasingly, this is being done now with minimally invasive techniques laparoscopically or robotically.[9, 10]  However, there have been no large studies that compare transvaginal repair to minimally invasive transabdominal approaches.[11]

Ureterovaginal fistulas may be treated with an internal stent. However, persistent fistulas despite stent placement warrant surgical exploration and ureteral reimplantation.

Important: The basic rule for fistula repair is that the first operation has the best chance of success, and surgeons should use the approach with which they feel most comfortable. All adjuncts should be included to ensure successful closure of the fistula.

Images of repair techniques are depicted below.

This patient developed a supratrigonal vesicovagin This patient developed a supratrigonal vesicovaginal fistula immediately over the right ureteral orifice after transabdominal hysterectomy for uterine fibroids. The right ureteral orifice has been cannulated with a ureteral catheter to prevent injury to the ureteral orifice during the fistula repair. A Foley catheter has been inserted into the bladder. A transvaginal repair was performed.

no

Percutaneous suprapubic tube is placed prior to re Percutaneous suprapubic tube is placed prior to repair of a supratrigonal vesicovaginal fistula.
The supratrigonal vesicovaginal fistula site is ma The supratrigonal vesicovaginal fistula site is marked out.
Supratrigonal vesicovaginal fistula. Isotonic sodi Supratrigonal vesicovaginal fistula. Isotonic sodium chloride is injected into the anterior vaginal wall to facilitate hydrodissection.
Supratrigonal vesicovaginal fistula. A J-shaped in Supratrigonal vesicovaginal fistula. A J-shaped incision is made, and the anterior vaginal wall is dissected off proximally and distally to the fistula. The fistula site is not excised. A generous flap is created anteriorly and posteriorly to the fistula site. Surgical sutures have been placed in the fistula to close the site.
Supratrigonal vesicovaginal fistula. Surgical sutu Supratrigonal vesicovaginal fistula. Surgical sutures are tied, and the fistula is closed.
Supratrigonal vesicovaginal fistula. Reinforcing t Supratrigonal vesicovaginal fistula. Reinforcing tissue layers are used to cover up the fistula site in a nonoverlapping fashion. In this case, peritoneum followed by pubocervical fascia was used.
Supratrigonal vesicovaginal fistula. Vaginal wall Supratrigonal vesicovaginal fistula. Vaginal wall is closed.

Preoperative Details

Informed consent discussions should include potential risks, including, but not limited to, ureteral injury, bladder injury, bowel injury, recurrence of fistula, persistent fistula, bleeding, and infection. Inform the patient if a Martius fat pad or gracilis muscle flap will be used.

Preexisting urinary tract infection should be cleared, and preoperative conjugated estrogen therapy is helpful. Broad-spectrum intravenous antibiotics are administered preoperatively.

Intraoperative Details

Transvaginal approach

Place the patient in a dorsal lithotomy position. Insert a percutaneous suprapubic tube and urethral catheter. Insert a posterior-weighted vaginal speculum and place a self-retaining vaginal retractor.

Identify the fistula and place traction sutures on the vaginal mucosa next to the fistula site. For traction, a small urethral catheter (8F) is inserted into the fistula. If the tract is very small, dilate the fistula to an acceptable size for urethral catheter insertion. The use of Fogarty balloon catheters and expensive catheters is unwarranted and adds unnecessarily to the expense of the procedure, as a regular (albeit smaller) Foley catheter usually suffices.

Using an inverted J-shaped incision, circumscribe the fistula site. Dissect the anterior vaginal wall off the underlying pubocervical fascia. Close the fistula tract (bladder mucosa) vertically using 2-0 or 3-0 absorbable sutures in a watertight fashion. Close the pubocervical fascia using 2-0 or 3-0 absorbable sutures horizontally. An additional layer of peritoneal-based flap from the posterior incision can be placed as a third layer. Excise the redundant vaginal mucosa. Approximate the vaginal incision using 2-0 absorbable sutures, without causing an overlapping suture line. Place Betadine -soaked packing in the vagina.

Alternatively, a Latzko partial colpocleisis technique can be used. In this technique, 2 concentric circular incisions around the fistula tract are made. The vaginal mucosa is excised in quadrants. The fistulous tract, pubocervical fascia, and vaginal mucosa are closed in layers, without overlapping suture lines.

When closure is difficult or tenuous, a Martius fat pad (pedicle flap) may be harvested from the labia majora and interposed. A cylindrical bundle of bulbocavernosus and pedicled fat are developed carefully, preserving the superior external pudendal artery. A capacious tunnel under the vaginal mucosa between the labia majora and the fistula site is then developed. The labial pedicle flap is brought through the vaginal mucosal tunnel and sutured to the edges of the fistula repair. The vaginal mucosa then is closed over the fat pad.

Transabdominal approach

Place the patient in a modified lithotomy position. Insert a urethral catheter. Make an infraumbilical incision and carry it down into the peritoneal cavity. Expose the pouch of Douglas. Completely mobilize the bladder and bivalve it at the dome. Identify the ureteral orifices and the fistula tract.

Cannulate both ureteral orifices with pediatric feeding tubes for easy identification. Circumscribe and excise the fistula. Separate the bladder from the vagina. Close the bladder with sequential 2-0 absorbable sutures after the vaginal closure is completed.

If omental interposition is performed, the abdominal incision should be carried to the epigastrium, with mobilization of the omentum. Separate avascular adhesions to the transverse colon. Divide and ligate the left gastroepiploic and short gastric vessels. Mobilize the omentum using the right gastroepiploic pedicle. Medially mobilize the ascending colon and hepatic flexure. Pass the omentum, which is hinged on the right gastroepiploic artery, behind the ascending colon and into the pelvis.

Close the vagina using 2-0 absorbable sutures. Suture the distal aspect of the omentum to the distal limits of the space between the vagina and the bladder. Complete the bladder closure in 1-2 layers. Put the suprapubic tube and pelvic drains in place.

If ureteral reimplantation is necessary, dissect out the ureter prior to fistulectomy. Reimplant the ureter in the upper bladder wall after the fistula is closed. The ureter should be stented postoperatively.

Laparoscopic and robotic approaches

In the era of more minimally invasive management (MIS), increasing experience in the use of robotic and laparoscopic technologies has yielded successes with vesicovaginal fistulae repairs.[12, 13] Adherence to similar principles as in open abdominal repair with use of interposition grafts and layered closures has produced reports of successful repair. Often, there is a fair amount of scarring and extravasation in the area of the fistula, which may affect the quality of the repair. Nonetheless, the use of MIS technology for this type of repair is increasing.[11]

 

Postoperative Details

Continue intravenous antibiotics until the patient is able to tolerate an oral diet. To prevent bladder spasms, prescribe anticholinergics. Remove pelvic drains when the output becomes minimal, usually prior to discharge.

Complications

Potential complications associated with repairing large vesicovaginal fistulas include the development of transient vesicoureteral reflux or de novo detrusor instability. Reflux and bladder spasms resolve spontaneously with anticholinergic therapy.

If a large fistula is present, the nearby ureteral orifice is at risk of becoming obstructed during the repair. If this is the case, the ureter must be reimplanted during the initial operation. The most feared complication is the recurrence of fistula. If this occurs, a proper waiting period is advised. The subsequent repair should be performed with a Martius flap, peritoneal interposition, or gracilis muscle flap.

Complications associated with ureterovaginal fistula repair include urinary extravasation and ureteral stricture formation. Persistent urinary leak can be treated with percutaneous nephrostomy drainage, ureteral stent(s), and/or Foley catheter drainage. For short ureteral strictures, minimally invasive endoscopic treatments can be used.

Long-Term Monitoring

Remove the urethral catheter and perform cystography 10-14 days following surgery. Alternatively, intravesical methylene blue may be used. If extravasation is not evident, the suprapubic tube may also be removed. If a persistent leak is present, leave the suprapubic tube in place and perform cystography 2 weeks later. When the cystogram does not define extravasation, the suprapubic tube may be removed.